Article

Nursing Ethics 18(6) 802813 The Author(s) 2011 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733011410093 nej.sagepub.com

Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it
Young-Rye Park
Kunsan National University, Republic of Korea

Jin-A Kim
Korea Health Industry Development Institute, Republic of Korea

Kisook Kim
Changwon National University, Republic of Korea

Abstract This study investigated the perceptions and attitudes of ICU nurses towards the do not resuscitate (DNR) decision and changes in their nursing activities after implementation of the DNR decision in South Korea. A data survey was conducted in South Korea between August and October 2008, with a convenience sample of 252 ICU nurses who had more than one year of clinical experience. The data were collected via a self-administered questionnaire. Most of the nurses perceived the necessity of the DNR decision in cases where there would be no chance of patient recovery despite massive efforts. Very few of the nurses activities changed, either passively or actively, after implementation of the DNR decision. Moreover, the findings of this research provide suggestions for the future direction of the DNR decision and ethical nursing guidelines in South Korea. Further investigations are needed for the development of decision-making skills and intervention guidelines for end-of-life nursing. Keywords do not resuscitate, ethics, intensive care unit nurses, perceptions

Introduction
The quantitative and qualitative development of modern medicine has contributed much to the prolongation of life through life-support systems, not only as a result of improvements in general health and the average life span, but also in the number of cases for whom medical treatment is considered useless.1 In particular, since the first successful cardiopulmonary resuscitation by massage of the outside of the heart following cardiac arrest in the early 1960s in the USA, cardiopulmonary

Corresponding author: Kisook Kim, Department of Nursing, Changwon National University, #9 sarim-dong, Changwon, Gyeongnam 641-773, Republic of Korea Email: kskim2011@changwon.ac.kr

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resuscitation (CPR) is now considered for all patients with cardiac arrest.2,3 However, not all patients who are resuscitated via CPR recover sufficiently to leave the hospital. Even in intensive care units (ICUs) with state-of-the-art monitoring systems, the report for 24-hour survival rate after successful CPR is only 9.2%.4 Indeed, there is currently considerable debate surrounding the use of CPR in patients with end-stage disease, some believing that it extends the patients life at the expense of the quality of life (i.e. such patients often suffer intense pain), and delays the expected process of death by merely maintaining heart and lung functions.3,5 In such cases, bearing in mind the chances of patient recovery and quality of life, the medical team and the patients family may choose to implement the do not resuscitate (DNR) decision.6 The concept underlying the increase in the implementation of the DNR decision is that the patients dignity is insulted if life-support treatment is continued despite the negligible (or zero) chances of recovery.7 Patients with serious conditions are treated in ICUs, and many biomedical problems of dying patients are encountered, with the DNR agreement most often being proposed by doctors.1 However, the exclusion of nurses from the DNR decision-making process may prevent them from playing their role as patient advocates, and make it difficult to consult and support the patients family. Nurses spend most of their time beside patients, and through effective communication with their patients and their families can play an important role in discerning their beliefs, values and wishes with regard to the ethical conclusions.8 Therefore, considering the environmental characteristics of the ICU, where visits from family members or caregivers are restricted and the patients critical health condition can rapidly deteriorate, establishing a value system and understanding about the DNR decision-making process among ICU nurses would be invaluable. Since DNR decisions involve the suspension or reservation of treatment from the patient, they may cause the doctors and nurses to do less than their best for the patients and to essentially give up on them, and so the decision and follow-up treatment or nursing should be carefully considered.9,10 The ethical problems related to this arise not only in making the DNR decision, but also in the changes made to the medical interventions and nursing activities associated with the patient after the decision is made. It has been reported that such medical interventions and nursing activities tend to be reduced after the DNR decision has been implemented.911 However, there has been little research into the development of ethical guidelines with regard to making the DNR decision, and the nursing activities implemented thereafter by the nurses in the ICU. In addition, the decision to implement the DNR protocol for dying patients is one of the most important issues influencing the relationship between the medical team and the patients caregivers. Some more-advanced countries have developed guidelines for the DNR decision and end-of-life care that are applicable to their own cultures, and have implemented ethical education. Such guidelines do not exist in South Korea, despite being needed.1 In response to this, a group of medical professionals in South Korea has announced the foundation of a special committee for establishing guidelines regarding the withdrawal of life-sustaining treatment; this committee has arranged a practical guide and provided ethical decision-making guidelines for each hospital and medical team.12 The use of these guidelines has resulted in the resolution of at least some of the ethical conflicts experienced by nurses in various medical environments13. However, it falls short with regard to specific methods that can help nurses, who take charge of the nursing and have an important impact on the familys decision making, to make a DNR decision and withdraw life-sustaining treatment based on nursing ethics. The aim of the present study was to determine the perceptions and attitudes of ICU nurses in South Korea towards DNR, and changes in their nursing activities after implementing the DNR decision. Based on these results, we discuss the current health-care situation with respect to the DNR decision in South Korea and other countries.

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Method Study design and subjects

This research was a descriptive survey involving a convenience sample of nurses selected from those who have worked for more than one year in ICUs of general hospitals in Seoul and Gyeonggi provinces in South Korea, and who agreed to participate after being explained the purposes of the study.

Instruments
We measured the following parameters: The nurses perceptions towards DNR. These were assessed using an instrument with 10 questions, plus one open-ended question, which was developed by Han et al.,14 and modified and supplemented by Kang.15 This instrument evaluated nurses general perceptions regarding DNR, such as its necessity and reasons for its selection, and the nurses preferences regarding DNR when confronted with making the decision for themselves. The ethical attitudes towards DNR. These were evaluated based on the tools of Lee et al.12 and Ko16. Using 19 questions, the nurses ethical attitudes about DNR were determined by asking questions relating to human life and the nursing field; there were three possible responses to these questions: agree, disagree and dont know. Various DNR-related cases were described, and the nurses responded to them with their own opinions. Cronbachs a for this part of the questionnaire was 0.64. The changes in nursing activities. These were induced by the implementation of the DNR decision, as measured by Jang.9 The activities questioned included basic nursing interventions such as morning care, tracheal suction, intravenous (IV) monitoring, communication and reporting the patients condition. The nurses were asked to check the degree to which these activities changed after the DNR decision was made, reflecting their experiences. It was composed of 17 questions totally, and measured the change in nursing activities asking no change, more passive, more active, regular or not applicable (N/A). Cronbachs a for this part of the questionnaire was 0.96.

Data collection and ethical considerations

Before commencing the research, its purposes were explained to the subjects, who then gave their informed consent to participate, and ethical approval was received from each of their nursing directors and unit managers. The researchers then consulted two nursing professors with ethical problems regarding the research process and the instruments to be used. The subjects took part in the research voluntarily; they were told that they could withdraw from the study at any point, that the results would be used only for research purposes and that their anonymity was guaranteed. The survey was processed in six conveniently selected university hospitals between August and October 2008, in Seoul, Korea; 50 subjects were enrolled from each hospital. Of these, 48 subjects were subsequently excluded because their responses were incomplete, leaving a total of 252 subjects in the analysis.

Data analysis
The collected data were analysed using SPSS 15.0 software. Frequencies and percentages were calculated from the data to evaluate the subjects general characteristics, perceptions of DNR, ethical attitudes and the change in their nursing activities after the DNR decision is made.

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Table 1. Demographic characteristics (n252) Characteristics Age Categories 2029 years 3039 years 40 and more Less than 3 years 35 years Over 5 years Less than 3 years 35 years Over 5 years Medical ICUs Surgical ICUs Others Staff Nurse Charge Nurse Head Nurse Have None Married Unmarried Associate degree Bachelors degree Masters degree and higher Yes No Yes No n (%) 213 (84.5) 37 (14.7) 2 (0.8) 115 (45.6) 59 (23.4) 78 (31.0) 135 (53.6) 58 (23.0) 59 (23.4) 96 (38.1) 117 (46.4) 39 (15.5) 240 (95.2) 9 (3.6) 3 (1.2) 141 (56.0) 111 (44.0) 33 (13.1) 219 (86.9) 115 (45.6) 127 (50.4) 10 (4.0) 62 (24.6) 190 (75.4) 202 (80.2) 50 (19.8)

Years of RN experience

Years of ICU RN experience Type of ICU

Position

Religion Marital status Education level

Experience of ethical education within 1 year Experience of DNR patient care

Results General characteristics

The general characteristics of the subjects (n 252) are given in Table 1. Most of them were in their 20s (84.5%), and the most frequent duration of entire working experience and experience in ICU was stated as being less than 3 years (45.6% and 53.6%, respectively). Surgical ICUs were the most common type of ICU (46.4%), and most of the nurses held the position of staff nurse. Furthermore, 56% of the nurses followed a religion, 86% were unmarried and 50.4% had a bachelors degree. Particularly relevant to the present study was that 62 (24.6%) of the nurses had experience of ethical education within one year of the commencement of the present study, and 202 (80.2%) had experience of DNR patient care.

Nurses perception of the DNR decision

Table 2 gives the results of nurses perceptions on the DNR decision. Most of the subjects (n 242, 96.0%) considered that DNR was sometimes necessary, with the cited reasons including terminal medical condition (n 129, 51.2%), comfort and a dignified death (n 116, 46.0%) and medical cost saving (n 7, 2.8%). In answer to the question for what reason is DNR unnecessary?, more than half of the subjects (n 129, 51.2%) answered when it is uncertain whether DNR should be implemented. A total of 133 nurses (52.8%) said that the DNR decision should be made according to the patients and familys wishes, and

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Table 2. Nurses Perceptions of DNR (n 252) Items Necessity of DNR Categories

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n (%) 242 (96.0) 10 (4.0) 116 (46.0) 129 (51.2) 7 (2.8) 57 (22.6) 133 (52.8) 54 (21.4) 8 (3.2) 53 (21.0%) 14 (5.6) 129 (51.2) 22 (8.7) 34 (13.5) 250 (99.2) 2 (0.8) 51 (20.2) 76 (30.2) 71 (28.2) 54 (21.4) 137 (54.4) 28 (11.1) 87 (34.5) 235 (93.2) 6 (2.4) 11 (4.4) 80 (31.7) 12 (4.8) 158 (62.7) 2 (0.8) 139 (55.2) 9 (3.6) 104 (41.2)

Yes No Reason for necessity of DNR Comfort and a dignified death Terminal medical condition Medical cost saving Responsible decision maker for DNR Patient only Patient and family Family and physician Others Reason for unnecessary of DNR Duty for health care provider Legal issues Uncertain of decision time Uncertain of responsible decision maker Potential negligence of treatment or nursing care Necessity of explaining about DNR to patient and family Yes No Appropriate time to explain about DNR When the patient is admited to ICU When the patient becomes comatose When the patient stops self-respiration Others Increased nursing needs after explanation about DNR Yes No I do not know Necessity of DNR guideline Yes No I do not know Intention to make DNR decision for a member of my family Yes No Up to the situation Others Intention to DNR decision for myself Yes No Up to the situation

almost all of the subjects (n 250, 99.2%) answered that explanations of DNR are necessary. With regard to the appropriate time for that explanation, 76 nurses (30.2%) answered when the patient becomes comatose, followed by when the patient stops self-respiration (n 71, 28.2%), and when the patient is admitted to the ICU (n 51, 20.2%). As for the intention to make the DNR decision, 158 nurses (62.7%) would consider DNR (depending on the medical condition) for a member of their family, and 139 (55.2%) would agree to DNR for themselves.

Nurses attitudes towards DNR

The results of the nurses attitudes towards DNR are given in Table 3. Of the 252 nurses, 193 (76.6%) agreed that the patients wish should be accepted when he or she is aware of a terminal medical condition and refuse treatment and care, and 179 (71.0%) responded that if the patients does not want it, DNR should not be

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Table 3. Ethical attitudes toward DNR (n 252) No 1 2 Contents The patients wish should be accepted when he or she is aware of a terminal medical condition and refuse treatment and care If the family wants, mechanical ventilator should be withdrawn in unconscious patients who are dependent upon it to sustain their life Even the dying patient should continue to be extended to live by almost all available methods The DNR decision should be made by the attending physician who is fully aware of the patients medical condition If the patients does not want it, DNR should not be implemented for any medical condition Medical staff should perform CPR on a patient in emergency situation although there is no hope of surviving if DNR decision is not made. Medical staff should do their best in other treatments although CPR is held in DNR patients Medical staff should always inform to the patient about his/her condition when there is no hope of surviving. Nurses should explain the bare fact to the patients and their family The condition should be explained frankly to them despite causing shock in case of condition near to death Family should be with a patient in ICU when DNR decision is made. The mechanical ventilator should be used at a minimum after declaration of DNR. The DNR decision must be made based on the DNR guidelines The familys requests should be respected if they want aggressive treatment such as CPR at the point of death even after the DNR decision has been made Basic nursing care should be minimized for the patients physical and psychological comfort after declaration of DNR Nurse should advise immediately when he/she observes that a nurse colleague does not apply aseptic techniques in DNR patients. Nurse should notify the physician about the DNR patients condition whenever it changes. It is natural for physician to decrease the concerns about patients after DNR decision is made. Nurse should advocate for the family who complain about decreased physicians concerns in DNR patients. Agree n (%) 193 (76.6) 73 (29.0) Do not know n (%) 42 (16.7) 100 (39.7)

807

Disagree n (%) 17 (6.7) 79 (31.3)

3 4 5 6

28 (11.1) 56 (22.2) 179 (71.0) 204 (81.0)

58 (23.0) 71 (28.2) 46 (18.3) 25 (9.9)

166 (65.9) 125 (49.6) 27 (10.7) 23 (9.1)

7 8 9 10 11 12 13 14

111 (44.0) 128 (50.8) 174 (69.0) 191 (75.8) 80 (31.7) 85 (33.7) 193 (76.6) 185 (73.4)

72 (28.6) 83 (32.9) 49 (19.4) 43 (17.1) 54 (21.4) 92 (36.5) 45 (17.9) 45 (17.9)

69 (27.4) 41 (16.3) 29 (11.5) 18 (7.1) 118 (46.8) 75 (29.8) 14 (5.6) 22 (8.7)

15 16

42 (16.7) 217 (86.1)

40 (15.9) 22 (8.7)

170 (67.5) 13 (5.2)

17 18 19

214 (84.9) 73 (29.0) 64 (25.4)

27 (10.7) 64 (25.4) 110 (43.7)

11 (4.4) 115 (45.6) 78 (31.0)

implemented for any medical condition. In terms of the familys wishes, 185 nurses (73.4%) agreed that the familys requests should be respected if they want aggressive treatment such as CPR at the point of death, even after the DNR decision has been made. Meanwhile, only 73 nurses (29.0%) agreed that if the family wants, mechanical ventilator should be withdrawn in unconscious patients who are dependent upon it to sustain their life.

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Table 4. Changes in Nursing activities after making the DNR decision (n 252) Items Bed making Morning Care Tracheal suction Chest percussion Position change and prevention care for pressure ulcer Pressure ulcer and wound care Simple massage CVP monitoring Vital Sign monitoring Body temperature control and hot/cold pack apply IV fluid monitoring and management Electrolyte monitoring / acid-alkali management Management of drain tubes Infection management Routine change of invasive lines Reporting the patients condition Active communication with family

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No change More passive More active Irregular n (%) n (%) n (%) n (%) 186 (73.8) 186 (73.8) 188 (74.6) 162 (64.3) 170 (67.5) 174 (69.0) 163 (64.7) 106 (42.1) 161 (63.9) 169 (67.1) 168 (66.7) 125 (49.6) 181 (71.8) 178 (70.6) 183 (72.6) 130 (51.6) 134 (53.2) 21 (8.3) 22 (8.7) 12 (4.8) 44 (17.5) 37 (14.7) 32 (12.7) 49 (19.4) 95 (37.7) 42 (16.7) 39 (15.5) 35 (13.9) 82 (32.5) 27 (10.7) 29 (11.5) 23 (9.1) 74 (29.4) 44 (17.5) 34 (13.5) 40 (15.9) 50 (19.8) 37 (14.7) 41 (16.3) 41 (16.3) 31 (12.3) 27 (10.7) 37 (14.7) 41 (16.3) 44 (17.5) 28 (11.1) 36 (14.3) 43 (17.1) 43 (17.1) 35 (13.9) 56 (22.2) 11 (4.4) 3 (1.2) 2 (0.8) 9 (3.6) 4 (1.6) 5 (2.0) 8 (3.2) 18 (7.1) 11 (4.4) 2 (0.8) 3 (1.2) 16 (6.3) 7 (2.8) 2 (0.8) 3 (1.2) 13 (5.2) 18 (17.1)

N/A n (%) 1 (0.4)

1 (0.4) 6 (2.4) 1 (0.4) 1 (0.4) 2 (0.8) 1 (0.4) 1 (0.4)

With respect to making the DNR decision, while 193 nurses (76.6%) agreed that the DNR decision must be made based on the DNR guidelines, only 56 nurses (22.2%) agreed that the DNR decision should be made by the attending physician who is fully aware of the patients medical condition. As to the question of the range of treatments, 111 nurses (44.0%) answered that medical staff should do their best in other treatments, even when CPR is withheld in DNR patients. As for basic nursing care, only 42 nurses (16.7%) agreed that basic nursing care should be minimized for the patients physical and psychological comfort after declaration of DNR. The breakdown of the responses to the statement the mechanical ventilator should be used at a minimum after declaration of DNR was as follows: agree (33.7%), dont know (36.5%) and disagree (29.8%).

Changes in nursing activities after making the DNR decision

Table 4 gives the results of the changes of nursing activities after the DNR decision was made. The leastchanged nursing activity was tracheal suction (n 188, 74.6%), followed by bed making (n 186, 73.8%), morning care (n 186, 73.8%), routine change of invasive lines (n 186, 72.6%) and management of drain tubes (n 181, 71.8%). Nursing activity that appears to become more passive is central venous pressure (CVP) monitoring (n 95, 37.7%), followed by electrolyte monitoring/acid-alkali management (n 82, 32.5%) and reporting the patients condition (n 74, 29.4%). The most actively changed nursing activity was active communication with the family (n 56, 22.2%), followed by tracheal suction (n 50, 19.8%) and IV fluid monitoring and management (n 44, 17.5%).

Discussion
The ethical perceptions and attitudes of ICU nurses towards DNR were investigated, and changes in nursing activities after the DNR has been made were determined in order to establish guidelines for nurses ethical

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decision making for DNR. Most (80.2%) of the nurses in the present cohort had experience of DNR, which is lower than the 92% in the study of Lee et al.12 However, 75.4% had experienced ethical education in the year preceding commencement of the study, which is higher than the 34.5% of general duty nurses12 and 43% of ICU nurses16 in previous studies. This suggests that education on ethics is increasing with the increased interest in social issues and the trend towards enhancing morality. This may be regarded as the effect of in-service education or other educations implemented as a result of highlighting the necessity of ethical education in nursing practice where ethical decision making is needed.

Perceptions about DNR

In the present study, the ICU nurses were aware of DNR as an ethical decision-making issue that is applied to unrecoverable patients. It is also an important ethical issue that should be referred to both the patients (where possible) and their family members. The DNR protocol should thus be implemented with proper process, according to appropriate guidelines. Many of our subjects felt that it would be decided depending on the circumstance in the case of their own family members, and their own unrecoverable condition, but that they would certainly apply it to themselves. This finding is in line with the results of previous research that surveyed the perception of DNR among doctors and nurses.3,15 Nurses try to induce patients and family members ethical decision making through continuous communication and preparatory information. In contrast, doctors perceive that they (together with the patients family members) should make the DNR decision, and 80% of doctors believe that DNR guidelines need to be established.15 In South Korea, most ethical decisions regarding the treatment of medical conditions are achieved through agreement between the patients family members and their doctors; the patients themselves are excluded from this process.1,3 However, the exclusion of patients and nurses from this decision-making process can induce a sense of guilt at a later date and reduce the nurses role.15 Therefore, legislation is required to maintain self-determination and autonomy with regard to life and death among patients, and to ensure that the decision is made ethically. Furthermore, the DNR decision-making process should be made systematically, and should take place early in the treatment process, like it is in developed countries. Since the decision-making process for the DNR protocol varies between countries according to health-care level, social customs, cultural background, religion, ethics and laws, it is necessary to regulate the process so that it fully reflects the patients autonomous decision making, taking into account the characteristics of South Korea and active participation from nurses who play supporting roles if the DNR decision is deemed necessary.

Attitudes towards DNR

Measuring attitudes towards ethical issues is highly subjective and relative, and the present study aimed to find significance with comparison and analysis based on previous research. Most of the nurses in the present study agreed that the opinion of the patients should be accepted with regard to their rejection of all treatments once they are informed that they are not going to survive. This is in accordance with the findings of Ko16 and Lee et al.13 who used the same measuring tool, and can be interpreted to mean that most doctors and nurses are opposed to the pointless expansion of treatment in cases where they have the patients agreement. Furthermore, the rejection by 65.9% of the subjects of the idea that the life of the dying patient should continue to be extended by almost all available methods can also be considered a rejection of painful and invasive treatments that are designed only to extend life. The general consensus from both this and previous research13,16 is that the treatment of DNR patients should be the same as before the DNR decision was made, except for the implementation of CPR. However, in all of this research 16.529.9% of subjects responded

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dont know or disagree to the question as to the types of treatment a DNR patient should receive. This suggests that there are changes in attitude towards DNR-determined patients, which will be discussed later; 16.7% of our subjects agreed that if DNR is declared, basic nursing care should be diminished for the patients comfort. Almost all subjects agreed that CPR should be performed on a dying patient who suffers a sudden heart attack and who needs CPR, but who had not made any decision regarding DNR. As to gaining agreement from the patient/family to DNR, 69% and 75.8% agreed to the statements that nurses should explain the bare facts to the patient and their family and the condition should be explained frankly to them, despite the shock, in cases where the patient is near to death, respectively. These rates are a little higher than those found in previous studies, whereby 45.157.0% of the subjects agreed that they had a duty to explain the DNR concept to patients and their families. Moreover, this painful process is considered desirable, based on the principal of respect for autonomy. There was ethical conflict among the nurses, as evidenced by the various reactions to questions related to the inclination of doctors and nurses to be relatively disinterested in their DNR patients.

Changes in nursing activities after implementation of the DNR decision

The responses to most of the items suggested that ICU nurses do not change their nursing activities according to the presence or absence of a DNR directive. Among these activities, bed making, morning care, tracheal suction, management of drain tubes, infection management and routine changes of invasive lines were nursing activities that remained unchanged regardless of a DNR decision. This can be seen as an intention to maintain their patients dignity by implementing daily hygiene nursing, even for those patients from whom treatment had been withdrawn. This concurs with the finding of Jang9 that measuring vital signs and monitoring and regulating IV fluid were performed on dying ICU patients, for whom focused monitoring and nursing are conducted 24 hours a day. The activities that changed passively, in spite of differences in the timing between the studies, were mostly those related to monitoring through fundamental nursing and invasive treatments. These findings can be interpreted as consideration of the dying patients comfort and intention to control the nursing manpower for patients with a greater likelihood of resuscitation. In addition, 29.4% of the nurses answered that reports on patients conditions changed passively, but 22.2% reported that there was a more active change in active communication with the family. Nurses perceive that the treatment activities of doctors after deciding upon the DNR directive are mostly passive,9 which is similar to what was found in a previous study, whereby the changes in medical interventions and attitudes towards cancer patients after deciding DNR were negligence, restrictive treatment and maintaining basic treatment.10 This suggests that the reporting of their patients condition changed passively due to prediction of a reduction in medical treatments and interventions. Discordant results have been observed regarding communication with the family in many studies. It is not easy to communicate with the family because nursing patients with limited nursing manpower represents a huge burden, because of the environmental limitation of restricting family visiting in the ICU, and because of the cultural characteristics of South Korea, whereby death is often not mentioned and is not dealt with openly. Sherman17 mentioned that whilst nurses recognized the reduction of basic nursing intervention for patients after implementing the DNR directive, monitoring and checking were actually more reduced than treatment, and that the sociopsychological treatment towards the patients and family did not change. The unfamiliarity with the DNR decision and the lack of understanding by nurses that they can themselves take firm attitudes towards ethical issues and make decisions, also seem to affect the transition into passive nursing activities. Moreover, the making of a DNR decision requires careful consideration and attention by nurses due to the psychological and spiritual demands on the family, thereby requiring more active efforts by the nurses involved. In particular, since ICU nurses are often exposed to the decision-making situation of DNR, they

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hold an important position for supporting and helping the patients family; they should therefore be able to provide proper nursing to the family of patients in a critical condition by continual and consistent interactions with them.

Current conditions of DNR and applications to ethical nursing decisions

The DNR decision-making process differs from country to country. All states of the USA have a legislative system for advanced directives.18 In contrast, in the UK the British Medical Association has only recently discussed the introduction of advanced directives,19 and there is no legislation for decision making about death by patients themselves. In Japan, as in South Korea, the Japanese Medical Association has officially declared that patients requests for death with dignity should be respected, but advanced directives have no legal standing.20 In South Korea, most ICU doctors believe that advanced directives are necessary. However, 90% of hospitals do not have an appropriate form, and it was reported that only 64% of hospital ethical committees provide any help with the DNR decision-making process, because of a lack of contribution to the practical withdrawal of life-sustaining treatment, although the necessity for its existence regarding the ethical decision of DNR is recognized.21 In this way the ICU nurses and doctors perceive the ethical need for a directive for the withdrawal of lifesustaining treatment, but this directive is used very infrequently due to the lack of publicity and the need for legal support for any guidelines. Korea does not have actual medical laws pertaining to the withdrawal and reservation of life-sustaining treatment, and hence efforts related to publicity and legislation for the national guidelines are necessary. In the DNR decision-making process, which ultimately results in the withdrawal and reservation of lifesustaining treatment, the dilemma of such ethical decision making can be minimized by making the decision based on objective information, actively reflecting the patients autonomous decision making, and coming to an agreement regarding the standards or guidelines for DNR in hospitals and medical societies overall. In addition, ethical decision making should be included in undergraduate medical/nursing education so as to minimize subsequent dilemmas relating to death, such as the decision to implement the DNR directive. Through this education, nurses can correctly perceive the ethical problems in clinical situations resulting from improvements in medical techniques, and develop the nursing ethic that the lives of others should be maintained and respected impartially by their nursing activities.

Study limitations
This research was conducted using a convenience sample of nurses working in the ICUs of general hospitals in specific regions, and as such its results cannot be generalized. Moreover, the lack of differences and relationships with the variables and subjects observed herein could be attributable to the basic instruments used, which were developed for a small cohort. Therefore, further research into the ethical implementation of the DNR directive is required.

Conclusion
The results of the present survey of ICU nurses perceptions and attitudes towards DNR revealed that most of them understood the necessity for the DNR directive in cases where the patient will not ultimately survive irrespective of treatment efforts. Regarding implementation of the DNR directive, the nurses believed that the will of patients and their family members is of utmost importance, and that it would be inevitable that they would have to explain the

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DNR directive to them. In addition, they thought that patients opinions should be accepted when they reject the treatment, when they are aware of the hopelessness of their condition, and that the treatment range for DNR patients should be to do their best with the exception of providing CPR. The nurses felt that emergent CPR should be applied to patients who have not had DNR explained to them, and that the information should be reported to both the family members and their patients, with basic treatment being continued even after making the DNR decision. The changes in nursing activities to a patient with a DNR directive are reduced passively to CVP monitoring, electrolyte monitoring, acidbase management and reporting on the patients condition, but nursing activities such as active communication with the patients family, tracheal suction and IV fluid monitoring are actively increased compared to before implementing DNR. Nurses perceptions and attitudes towards the DNR decision and the changes in nursing activities after implementing it were surveyed, and the direction for future work has been discussed. However, because this study was limited to a clinical selection of a specific region, we suggest that further research on nursing ethics related to the end of life in a more extensive region and more varied nursing departments is required. The development of guidelines adapted to clinical practice through such research will help nurses to act wisely when they are presented with ethical conflicts. Conflict of interest statement The authors declare that there is no conflict of interest. References
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